Thank you for making a booking with Fit n Well !!!
If this is your FIRST appointment with Fit n Well please complete this form below.
Doing this before your appointment will leave more time for the treatment itself.
If you have had a previous appointment with Fit n Well, you do NOT need to complete this page again.
Looking forward to seeing you at your appointment time…
Please note: from 1/7/17 the cost of a one hour treatment will be $80
Keep Fit and Well…Gary
Please do not alter this field above
What is your age?
If you are under 18 years of age you must have a parent or guardian present during the massage
Emergency contact details:
Please provide name, relationship and telephone number
Who is your family doctor (GP)
For remedial massage appointments:
For lymphatic drainage appointments please skip this section (see below)
Briefly describe your reason for booking a massage treatment.
For example "I have lower back pain that radiates down my left leg" or "I just want a massage to help me relax"
If experiencing any pain, was there a specific incident that caused it?
If experiencing any pain, how long have you been experiencing it for?
If experiencing any pain, how would you rate its severity?
0=no pain 10=extreme pain
Have you had a professional massage in the past?
If so what type of pressure do you enjoy?
For manual lymphatic drainage appointments:
Are you making an appointment one area or whole body?
Specific area of my body
Whole body MLD treatment
Briefly describe your reason for booking a lymphatic drainage treatment.
For example "I have fluid accumulation in my lower legs"
How long have you had this fluid accumulation for?
If a medical condition has caused the fluid accumulation please provide more information.
How much time have you allocated for your first appointment?
Do you currently take any regular medications?
Please give the name of the medication and the condition that it is treating
If you have private health fund cover for remedial massage please give the name of the fund.
Please give the name of the fund
What is your occupation?
How physical is your job?
How would you rate the level of stress that you experience from your job?
Not much stress at all
Please list any recreational activities or sports that you participate in.
Do you have any of the following conditions?
Any recent surgery
Any infectious diseases
Any form of cancer
None of the above
If you have any of the above conditions please explain further.
Other conditions, please check the box if you have any of these.
Areas of broken skin
Constipation or other digestive issues
Spinal problems (disc herniation etc.)
None of the above
If you have any of these other conditions please explain further.
Is there the possibility that you are pregnant?
If YES how many weeks?
Do you take any blood thinning medications like aspirin, warfarin etc.
Do you bruise easily if you bump into objects?
Consent to provide treatment
You are booking in for a treatment where removal of some clothing will be required to effectively access the area of your body being treated. I am a professional massage therapist & I adhere to strict body draping procedures. During the treatment, your privacy will be respected at all times by covering your body with draping towels, only the body part being treated will be un-draped. I am a member of the Association of Massage Therapists (Member Number 1-10757), and abide by their Code of Ethics.
Persons under 18 years of age are requested to wear sporting attire to the massage appointment.
I hereby give my consent for Gary Bolton to carry out the treatment as detailed above and discussed with my therapist (Gary Bolton) before the consultation.
Please type your name indicating consent
If you have any questions or concerns relating to the treatment please state them here.
How did you find out about FitnWell Massage?
If referred by a friend please mention your friend's name